Wednesday, 18 September 2013

NovitaBudimanFaraby-Rio-Puteri

Male, Mr Y 59 y.o
Chief complain
Patient is consulted from the Internal Medic Department with decreased Consciousness susp due to Intracranial Process dd CVD. Also suspected Endopthalmitis RE

History (Alloanamnesa from his wife)

8 Hours b.a patient looks inadequate in contact with his family and his family bring to RSCM from RSUD Bekasi, no seizure, 2 weeks before patient have redness and pain felt in his right eye, blur vision +, discharge + yellowish, fever , And 1 weeks before his RE looks yellowish Treatment history of betle leaf -, Urine water

History (Alloanamnesa from his wife)

No History of Trauma neither Surgical operation Eye before, No history of eye redness before this Patient came to Opthalmologist and got treatment Timolol 2xRE, Polygran 6x RE, Lyteers 6x RE and refer to RSCM. But before patient came to RSCM patient felt shortness of breath and weakness of the both side with slurred lingual sound. Patient was inward in the RSUD Bekasi for 11 day, His family move the patient by own will to the RSCM due to worsen progress, There is no medical record history or Referral Letter from RSUD Bekasi.

History (Alloanamnesa from his wife)

History DM 15 yrs and the last 5 month patient didnt controlled to the doctor, Last therapy insulin 3x10 IU History of kidney failure with fix scheduled Hemodialysis 2x/week in RSUD Bekasi Drugs Allergy + suspected Ab ? Asthma-, Spectale -

Ophthalmological Status
Patient compos mentis, RE Pain
RE LE

Hard to be evaluated
5 mmHg i-care Hard to be evaluated Edema (+), spasm (+), Lagopthalmos + 3mm, Corneal Exp 1mm

VA
IOP M

Hard to be evaluated
9 mmHg i-care Hard to be evaluated

EL

Normal

Chemotic (+) All Quadrant Infiltrat at the inferior site 2x5mm

BC C

Normal Clear

Ophthalmological Status
Deep, Hipopion, with coagulum, AC pus? Hard to be evaluated Hard to be evaluated Hard to be Evaluated I/P L deep Round, central, LR (+), consensual reflex (-) Hazy gr 3

Clear
Round papil, distinc edge, aa/vv 2/3, MR +, Infiltrat at the Choroid

Hard to be Evaluated

Blood Profile
Lab
Hb Ht L Tr GDS SGOT SGPT 8.08 23.2 10.900 194.000 163 35 44 Ureum Creatinin Uric Acid Albumin 180.6 8.4 13.4 2.23

 Suspect Panopthalmitis RE susp Focal infection from ISK with Pyuria dd Hospital Acquired Pneumonia Choroiretinitis LE due to susp Candida Senile Cataract LE Lagopthalmos RE Keratitis Exposure RE Unconsciousness susp due to Intracranial process dd cerebro vaskular disease

Chronic Kidney Disease on HD with Anemia DM tipe 2 controlled, HT gr 2 Hipoalbumin with Pitting Edema History of Allergy Drug Eruption susp Antibiotics? Chronic Suppurative Otitis Media N VII Paralysis susp due to intracranial process dd vascular disease

Plan Opthalmology Department

Levofloxacin 1x500mg iv change to Meropenem 3x1 gram by Internal Medicine Levofloxacin ED hourly RE SA ED 1% 2xRE Lid Tapping OE during unconscious Kemicetine 3 x OE

Consult to Dentist Department Search Focal Infection

Perform USG OD

Perform Blood and Urine Culture both bacterial and fungi

Cenfresh 6x OE

 Go to Otolaryngx outward clinic when possible CT scan mastoid No Emergency treament in our Department

Meropenem 3x1 gr iv Bignat 3x1 OMZ 1x40 gr iv Allupurinol 1x100mg Folic acid 1x1 Vit b12 3x1 Sucralfat 4x1 Famadol 3x1 gr Insulin sliding scale

Check Urinalysis, Thorax X-ray

Routinely Hemodialysis

Neurologi
Perform CT Scan Brain with and without contrast Other therapy follow Internal Medicine

Pemeriksaan Penunjang USG mata kanan

Kesan :Vitreous keruh dengan spike tinggi

 Assessment Keratitis Exposure RE Panopthalmitis RE and Chorioretinitis ec susp Candida

Plan
Pro CITO Eviceration + DFG RE
LFX 6 hourly RE Cenfresh 6x OE Lid Tapping Kemicetine 3 x OE

Other follow Internal Medicine

Will Be Follow up today.